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- 1. Femoral Neck Fractures BY DR/KHALED ALSAYANI
- 2. Hip fracturesin the elderly can be life altering. Overall 30 day mortality is 9%, development of medical complications increases the rate further, pneumonia alone increases mortality to 43% and heart failure increases it to 65%49 and mortality at 1 year is 15%–20%.
- 3. Epidemiology > 300,000Hip fractures annually in the US Accounts for 30% of all hospitalizations Expected to surpass 6 million annually worldwide by 2050 Significant morbidity, mortality, expense $10-15 billion/year in the US
- 4. Epidemiology: Bimodal Distribution Elderly incidence doubles each decade beyond age 50 higher in caucasians smokers, lower BMI, excessive caffeine
- 5. Plain Film Consider traction-internal rotation view if comminuted CT scan Displacement comminution Diagnosis
- 6. MRI Forevaluation of occult femoral neck fracture Consider MRI in an elderly patient who is persistently unable to weight bear 100% sensitive and specific May reduce cost by shortening time to diagnosis Diagnosis
- 7. Classification Garden (1961) Degree of displacement Relates to risk of vascular disruption Most commonly applied to geriatric/insuffiency fractures
- 8. Garden Classification I Valgusimpacted or incomplete II Complete Non-displaced III Complete Partial displacement IV Complete Full displacement
- 9. Treatment Goals: GeriatricPatients Mobilize Weight bearing as tolerated Minimize period of bedrest Minimize surgical morbidity Safest operation Decrease chance of reoperation
- 10. Treatment Options Non-operative Limitedrole Usually high operative risk patient Valgus impacted fracture Elderly need to be WBAT Mobilize early
- 11. Treatment Options Reductionand fixation Open or percutaneus Arthroplasty Hemi or total
- 12. Decision Making Variables: PatientFactors Young (active) High energy injuries Often multi-trauma Often High Pauwels Angle (shear) Elderly Lower energy injury (falls) Comorbidities Pre-existing hip disease
- 13. Decision Making Variables: FractureCharacteristics Displacement Stability
- 14. Pre-operative Considerations: Geriatric SurgicalTiming Surgical urgency in relatively healthy patients decreased mortality, complications, length of stay Surgical delay up to 72 hours for medical stabilization warranted in unhealthy patients 2.25 increase in MORTALITY if > 4 day delay Most likely related to increased severity of medical problems
- 15. Treatment Issues: GeriatricPatients Fixation Lower surgical risk Higher risk for reoperation Replacement Higher surgical risk (EBL, etc.) Fewer reoperations Better function
- 16. Treatment Issues: GeriatricPatients Fixation Stable (valgus impacted) fractures Minimally displaced fractures Replacement Displaced fractures Unstable fractures Poor bone quality
- 17. Arthroplasty Issues: Hemiarthroplasty versusTHA Hemi More revisions 6-18% Smaller operation Less blood loss More stable 2-3% dislocation Total Hip Fewer revisions 4% Better functional outcome More dislocations 11% early 2.5% recurrent
- 18. Arthroplasty Issues: Surgical Approach Posterior 60% higher short-term mortality Higher dislocation rate Anterior/Anterolateral Fewer dislocations
- 19. ORIF or Replacement? Prospective, randomized study ORIF vs. cemented bipolar hemi vs. THA ambulatory patients > 60 years of age 37% fixation failure (AVN/nonunion) similar dislocation rate hemi vs. THA (3%) ORIF 8X more likely to require revision surgery than hemi and 5X more likely than THA THA group best functional outcome
- 20. Special Problems Stress Fractures Patient population: Females 4–10 times more common Amenorrhea / eating disorders common Femoral BMD average 10% less than control subjects Hormone deficiency Recent increase in athletic activity Frequency, intensity, or duration Distance runners most common
- 21. Nonunion 0-5% inNon-displaced fractures 9-35% in Displaced fractures Increased incidence with Posterior comminution Initial displacement Imperfect reduction Non-compressive fixation
- 22. Osteonecrosis (AVN) 5-8%Non-displaced fractures 20-45% Displaced fractures Increased incidence with INADEQUATE REDUCTION Delayed reduction Initial displacement associated hip dislocation Sliding hip screw / plate devices
- 24. Total hip arthroplasty(THA) The total hip arthroplasty (THA) is an orthopedic procedure that is performed 280 000 times annually in the United States of America . THA is one of the most common surgical procedures performed in the US and worldwide
- 25. INDICATIONS FOR THA severe osteoarthritis rheumatoid arthritis avascular necrosis traumatic arthritis hip fractures benign and malignant bone tumors arthritis associated with Paget’s disease ankylosing spondylitis juvenile rheumatoid arthritis.
- 26. Rehabilitation Protocol THA postoperativeconcerns Most THA procedures require the presence of an abduction pillow or wedge placed between the legs when the patient is in bed or in a wheelchair. Patients are cautioned not to exceed 90° of flexion of the operative hip. Passive or forcible movement of the hip that causes pain is contraindicated. Internal rotation and adduction are contraindicated. The patient is encouraged to perform active ankle exercises No weight-bearing or standing should take place unless under the direct supervision of the physical therapist.
- 27. Homecare instructions forTHA patients First 6 weeks postoperatively: Do not Sit in low chairs or sofas Cross legs Force operated leg to flex (bend) or rotate at the hip Sit down on the floor of a bath tub Lean forward or raise knee higher than hip Discard the walking assistive device until instructed to do so Drive until permitted Force hip abduction, external rotation or extension
- 28. Do Use helpfor putting on shoes and stockings Use compression stockings Exercise as instructed Sleep on back Place a pillow between knees when sitting or sleeping Use caution getting into and out of bed and on and off a toilet seat.
- 29. Outpatient Discharge Criteria Walking normally without any assistive device Negotiate stairs reciprocally and safely Getting in/out of a car without difficulty Donning/doffing shoes and socks without difficulty
- 30. Phase 1: Post-opPhase (Day 0- Hospital Discharge) Goals Control pain and swelling Protect healing tissue Begin to restore range of motion (ROM) Establish lower extremity muscle activation Restore independent functional mobility Educate the patient regarding their dislocation precautions Precautions Dislocation precautions WBAT with crutches or walker unless otherwise ordered Screen for sensory/motor deficits Screen for DVT, symptomatic orthostatic hypotension, symptomatic low hematocrit
- 31. Recommended Exercises (All exercisesperformed within the patient’s dislocation precautions) Range of Motion Heel slides Ankle pumps Supine hip internal/external rotation Strength Quad sets Glut sets Hamstring sets Supine hip abduction/adduction Long arc quads (LAQ) Seated hip flexion Short arc quads (SAQ)
- 32. Functional Mobility Bedmobility Transfer training Gait training on level surfaces Stair training ADL’s with adaptive equipment as needed Positioning (when in bed) Posterior Precautions: ensure the foot of the bed is locked in a flat position Use a trochanter roll to maintain hip in neutral rotation and promote knee extension Never place anything under the operated knee for posterior precautions. Use of abduction wedge when in bed at all times unless otherwise ordered Use of hip chair (posterior approach) when appropriate
- 33. Guidelines Perform 10repetitions of all exercises 3-5 times a day. Use ice after exercising for 10-20 minutes. Inpatient Plan of Care Day of Surgery Out of bed to a chair Post Op Day 1 PT and OT Evaluations Therapeutic Exercise including ROM, Strengthening, and Functional Mobility as appropriate ADL Training as appropriate Post Op Day 2-Discharge Progression of Therapeutic Exercise and Functional Mobility Continued ADL Training
- 34. Phase 2: MobilityPhase (Hospital Discharge-6 Weeks) Goals Begin to restore muscle strength throughout the operated leg Initiate proprioceptive training Initiate endurance training Normalize all functional mobility Demonstrate normal gait pattern with goal to wean all assistive devices at the end of this phase (if permitted by surgeon)
- 35. Precautions Dislocation precautions WBAT with crutches or walker, progressing to cane unless otherwise ordered Monitor for proper wound healing Monitor for signs of infection Monitor for increased swelling
- 36. Recommended Exercises (Allexercises performed within the patient’s dislocation precautions) Range of Motion Continue with all phase 1 ROM exercises Stretching Initiate gentle hamstring, gastroc/soleus, and quadriceps stretching Strengthening Continue quad sets, glut sets, hamstring sets Continue LAQ and seated hip flexion Bridging Standing hip flexion/ abduction/ adduction/ extension Progress to straight leg raises (SLR), hip abduction/ adduction/ extension against gravity towards the end of this phase Progress to closed chain exercises including terminal knee extensions, mini-squats, step ups, and mini-lunges by the end of this phase
- 37. Proprioception Weight shiftingactivities Single leg stance Functional Mobility Gait training with appropriate device emphasizing normal gait pattern Stair training with appropriate device Endurance Initiate stationary biking with minimal to no resistance 3-4 weeks post-op Guidelines Perform 10-20 repetitions of all ROM, strengthening, and strengthening exercises 3x/day. Hold stretches for 30 seconds and perform 2-3 repetitions of each. Bike daily for 5-10 minutes if able.
- 38. Phase 3: StrengtheningPhase (6-12 Weeks) Goals Restore normal LE strength Return to baseline functional activities Precautions Dislocation precautions Avoid high impact activities Avoid activities that require repeated pivoting/twisting
- 39. Recommended Exercises (Allexercises performed within the patient’s dislocation precautions) Range of Motion and Stretching Continue ROM exercises from phase 1 and 2 until ROM normalized Strengthening Continue with phase 2 exercises adding and increasing resistance as tolerated Add resistance machines as appropriate including leg press, hamstring curl, and 4-way hip machine Emphasize eccentric control of quadriceps and hip abductors with closed chain exercises Proprioception Single leg stance Static balance on Bosu/wobble board/foam/etc Add gentle agility exercises (i.e. tandem walk, side stepping, backwards walking)
- 40. Endurance Continue biking,adding mild to moderate resistance as tolerated Begin walking program Guidelines Perform ROM and stretching exercises once a day. Hold stretches for 30 seconds and perform 2-3 repetitions of each. Perform strengthening exercises 3-5 times a week. Do 2-3 sets of 15- 20 Reps.
- 41. Phase 4: AdvancedPhase (12 Weeks and Beyond) Goals Continue to improve strength to maximize functional outcomes Work with to create customized routine to allow return to appropriate sports/ recreational activities Precautions Dislocation precautions according to surgeon’s orders Avoid high impact and contact sports Avoid repetitive heavy lifting
- 42. Recommended Exercises (Allexercises performed within the patient’s dislocation precautions) ROM and Flexibility Continue daily ROM and stretching exercises Strengthening Continue with all strengthening exercises increasing resistance and decreasing repetitions Proprioception Continue with all phase 3 exercises, increasing difficulty as tolerated. Endurance Continue with walking, biking, elliptical machine programs Functional Progression Activity/sport-specific training exercises
- 43. Guidelines Perform ROMand flexibility exercises daily. Perform strengthening and proprioception exercises 3-5x/ week, performing 2-3 sets of 10-15 repetitions. Continue endurance program 30-45 minutes 3x/ week.